IPHREHAB :OCCUPATIONAL THERAPIST ASSESSMENT AND INTERVENTION FOR MOTOR LEARNING

IPHREHAB

Assessment

• OCCUPATIONAL THERAPIST Assessment includes:

1. Dynamic evaluation, watching client during occupational performance, including responses to cues.
2. Collaboration with client to determine occupational problems and priorities.
3. Evaluation of person, task, & context, to determine appropriate OT interventions.

Assessment

• OT evaluations may incorporate manual muscle tests, range of motion, strength & endurance tests, which directly relate to problems with specific task performance.
• Sensory & perceptual evaluations stem from client-identified problems with those aspects of task performance.
• Cognitive evaluations may further clarify difficulties with awareness, goal identification, motor planning, and generalization of learning.

INTERVENTION

• Client-centered role/task selection
• Discussion of OT assessment results
• Collaboration which includes therapeutic use of self in determining and/or raising level of client self-awareness
• Imparting information on current evidence with regard to a choice of approaches
• Practice of needed skills in natural settings

Motor Learning Interventions

• Prevention of injury/dysfunction through splinting, positioning, educating, & sensitization to relevant environmental cues.
• Promoting function through individualized task problem-solving & collaborative experimentation about the best way to accomplish the task.

• Practicing whole tasks, not isolated parts.
• Providing skill practice in varied contexts during daily routines.
• Providing randomized practice (changing parameters or circumstances).
• Providing intermittent feedback during task performance or summarized at end.
• Encouraging self-evaluation & error detection (both KP & KR).

Interventions

• Modify task demand in order to achieve task goal (use e-mail instead of telephone to communicate with others; use alarm to remember next step).
• Modify contextual factors in order to achieve task goal (use bolsters to position for active movement in playing a game).

Intervention: Constraint-Induced Movement Therapy

• Contemporary variation of task-focused approach for stroke survivors (1 year post-stroke).
• Consists of “constraining” nonaffected arm, forcing use of affected limb for performing daily tasks. 
• In 2-week experiment, “constrained” group showed significantly greater motor skills, carry over to life tasks, and maintenance of gains in 2-year follow-up.
• Original study replicated (Blanton & Wolf, 1999) shows that 20% to 25% of clients with chronic stroke symptoms may benefit from this approach.

Please make your own copy of article. Focus on distinctions made between traditional & contemporary OT approaches. 

IPHREHAB : MOTOR LEARNING , FUNCTION AND DYSFUNCTION AND CHANGE WITH MOTIVATION

IPHREHAB


FUNCTION & DYSFUNCTION

• Gentile (1992): early & late stages of learning
• Fitts & Posner (1967):

1. Cognitive stage of motor learning (understanding of task, experimentation)
2. Associative stage: refined practice
3. Autonomous stage: skill relatively automatic
4. Example: child learning to climb stairs

Function 

• Degrees of freedom: refers to gradual increase in smoothness of performance of skilled movement. Example: using a hammer.
• Specific definitions for function & dysfunction have not been defined in occupational therapy (Kaplan & Bedell, 1999). 
• Definition of dysfunction in OT must include all three components: person, environment, & occupation.

CHANGE & MOTIVATION

• Holistic approach: OT ALWAYS incorporates practice of perception and movement within the context of SPECIFIC TASKS. 
• Client centered: Motivation comes naturally when clients and/or families set priorities for tasks to be accomplished & goals to be achieved. 
• Systems approach begins with role performance, considering the best combination of remediation, adaptation, & compensation in order to promote client-identified level of functioning to fulfill desired roles.

Change

• Change occurs through learning process.
• Recovery may be:

1. Spontaneous, without benefit of intervention
2. Forced recovery, function gained through therapeutic intervention, such as – example?
3. Adapted or functional recovery, attained through altering methods or contexts within which client accomplishes a task

Postulates of Change, cont.

• Defined in Pediatrics by Kaplan & Bedell. Motor skills more likely to improve when:

1. Match between child’s ability, task, & context.
2. Child understands expectation & receives clear guidance
3. Independent problem-solving encouraged
4. Just right challenge (zone of proximal development).

IPHREHAB : MOTOR LEARNING WITH Learning Theory and Behavior modification

IPHREHAB


Learning Theory (Behavior Modification)
Non-Associative Learning:

• Habituation: desensitization that results from repeated exposure to a nonpainful stimulus (e.g., Ignore stimuli that trigger nonfunctional responses)
• Sensitization: increased responsiveness (e.g., Pay attention to safety features, such as water on the floor, or obstacles in one’s path)

Learning

1. Associative Learning:

• Classical & operant conditioning (considers past and current environmental influences)
• Procedural learning: performed without conscious attention (develops slowly through many repetitions to become habitual, stored in brain as “movement schema”) (e.g., walking)
• Declarative learning: results in knowledge that can be consciously recalled, requiring awareness, attention, and reflection (e.g., words)

Learning

• Variable practice, using motor/perceptual skills under varying conditions, works best for generalization of learning
• Contextual interference, using motor perceptual skills in random order, increases spontaneous use for new tasks
• Individual characteristics, such as level or experience & intellectual ability influences motor learning
• Transfer of learning occurs more easily when tasks are similar (Toglia – near transfers)

Learning

• Schmidt’s “schema theory” uses sets of general rules that apply in variety of contexts
• Schema: a generalized motor program that consists of 4 parts:

1. Initial situation
2. Parameters used
3. Outcome (knowledge of result)
4. Sensory consequence (how movement feels)

• Example: swinging a golf club or donning a coat

Learning

• Newell’s Ecological Theory clarifies the role of perceptions in motor learning.

1. Recognition of goal or task
2. Regulatory cues (sensitize to what is relevant to the task)
3. Knowledge of Performance (KP): feedback during performance, how movement felt
4. Knowledge of Result (KR): feedback on goal achievement

IPHREHAB : MOTOR LEARNING FROM PAST TO PRESENT

IPHREHAB

 MOTOR LEARNING FROM PAST TO PRESENT

• Aim is to replaces Motor Control (NDT, etc.) as a more evidence-based approach to all forms of movement disorders across the lifespan (CP, TBI, CVA, etc.)
• Backdrop for Task Oriented approach defined by Horak (1991), Shumway-Cook & Woolacott (2001) and Mathiowetz, Bass Haugen & Flinn (in Trombly & Radomsky, 2002). 

Basic Assumptions

Motor Control – It is the ability to regulate and/or direct the mechanisms essential to movement (Shumway-Cook & Woolacott, 2001). AKA “neuromaturational” or “hierarchical” or “bottom up” theories of re-acquisition of voluntary movement.

Motor learning – Set of processes associated with practice or experience leading to relatively permanent changes in the capacity for producing skilled action (Shumway-Cook & Woollacott, 2001). Combines neuroscience with  systems & learning theory.

Assumptions, cont.

• Based in principle of neural plasticity – the ability of the nervous system to modify neural connections to perform more efficiently.
• Short term (working memory) – needed for learning new movements 
• Long term (save/retrieve) – needed for lasting change
• Motor learning occurs naturally during task performance (supports a task focused approach)

Systems Theory

1. Systems approach includes a consideration of :

• Client factors: health condition, dysfunction or damage, age, gender, etc.
• Occupations: meaningful or preferred tasks
• Environment: all relevant contexts.

1. Systems include sensorimotor, psychosocial, cognitive, and performance contexts (physical, socioeconomic & cultural characteristics of the task itself and the broader environment) (Mathiowetz & Bass Haugen, 1994).
2. Consistent with occupation-based models